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Chupradit S, Wamalwa DC, Maleche-Obimbo E, Kekitiinwa AR, Mwanga-Amumpaire J, Bukusi EA, Nyandiko WM, Mbuthia JK, Swanson A, Cressey TR, Punyawudho B, Musiime V. Population Pharmacokinetics of Pediatric Lopinavir/Ritonavir Oral Pellets in Children Living with HIV in Africa. Clin Pharmacol Ther 2024; 115:1105-1113. [PMID: 38247190 DOI: 10.1002/cpt.3174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 12/23/2023] [Indexed: 01/23/2024]
Abstract
Antiretroviral therapy for children living with HIV (CLHIV) under 3 years of age commonly includes lopinavir/ritonavir (LPV/r). However, the original liquid LPV/r formulation has taste and cold storage difficulties. To address these challenges, LPV/r oral pellets have been developed. These pellets can be mixed with milk or food for administration and do not require refrigeration. We developed the population pharmacokinetic (PK) model and assessed drug exposure of LPV/r oral pellets administered twice daily to CLHIV per World Health Organization (WHO) weight bands. The PK analysis included Kenyan and Ugandan children participating in the LIVING studies (NCT02346487) receiving LPV/r pellets (40/10 mg) and ABC/3TC (60/30 mg) dispersible tablets. Population PK models were developed for lopinavir (LPV) and ritonavir (RTV) to evaluate the impact of RTV on the oral clearance (CL/F) of LPV. The data obtained from the study were analyzed using nonlinear mixed-effects modeling approach. Data from 514 children, comprising a total of 2,998 plasma concentrations of LPV/r were included in the analysis. The LPV and RTV concentrations were accurately represented by a one-compartment model with first-order absorption (incorporating a lag-time) and elimination. Body weight influenced LPV and RTV PK parameters. The impact of RTV concentrations on the CL/F of LPV was characterized using a maximum effect model. Simulation-predicted target LPV exposures were achieved in children with this pellet formulation across the WHO weight bands. The LPV/r pellets dosed in accordance with WHO weight bands provide adequate LPV exposures in Kenyan and Ugandan children weighing 3.0 to 24.9 kg.
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Affiliation(s)
- Suthunya Chupradit
- PhD's Degree Program in Pharmacy, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
| | - Dalton C Wamalwa
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | | | | | | | - Elizabeth A Bukusi
- Centre for Microbiology Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Winstone M Nyandiko
- Department of Child Health and Paediatrics - Moi University, AMPATH and Moi Teaching and Referral Hospital, Eldoret, Kenya
| | | | - Alistair Swanson
- Drugs for Neglected Diseases Initiative, Geneva, Switzerland
- Drugs for Neglected Diseases Initiative, Nairobi, Kenya
- Drugs for Neglected Diseases Initiative, Bethesda, Maryland, USA
| | - Tim R Cressey
- AMS-PHPT Research Collaboration, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand
- Department of Molecular & Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Baralee Punyawudho
- Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
| | - Victor Musiime
- Joint Clinical Research Centre, Kampala, Uganda
- Department of Paediatrics and Child Health, Makerere University, Kampala, Uganda
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van der Laan LE, Garcia-Prats AJ, Schaaf HS, Winckler JL, Draper H, Norman J, Wiesner L, McIlleron H, Denti P, Hesseling AC. Pharmacokinetics and Drug-Drug Interactions of Abacavir and Lamuvudine Co-administered With Antituberculosis Drugs in HIV-Positive Children Treated for Multidrug-Resistant Tuberculosis. Front Pharmacol 2021; 12:722204. [PMID: 34690765 PMCID: PMC8531271 DOI: 10.3389/fphar.2021.722204] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 09/22/2021] [Indexed: 12/01/2022] Open
Abstract
Given the high prevalence of multidrug-resistant (MDR)-TB in high HIV burden settings, it is important to identify potential drug-drug interactions between MDR-TB treatment and widely used nucleoside reverse transcriptase inhibitors (NRTIs) in HIV-positive children. Population pharmacokinetic models were developed for lamivudine (n = 54) and abacavir (n = 50) in 54 HIV-positive children established on NRTIs; 27 with MDR-TB (combinations of high-dose isoniazid, pyrazinamide, ethambutol, ethionamide, terizidone, fluoroquinolones, and amikacin), and 27 controls without TB. Two-compartment models with first-order elimination and transit compartment absorption described both lamivudine and abacavir pharmacokinetics, respectively. Allometric scaling with body weight adjusted for the effect of body size. Clearance was predicted to reach half its mature value ∼ 2 (lamivudine) and ∼ 3 (abacavir) months after birth, with completion of maturation for both drugs at ∼ 2 years. No significant difference was found in key pharmacokinetic parameters of lamivudine and abacavir when co-administered with routine drugs used for MDR-TB in HIV-positive children.
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Affiliation(s)
- Louvina E. van der Laan
- Department of Paediatrics and Child Health, Desmond Tutu TB Centre, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Department of Medicine, Division of Clinical Pharmacology, University of Cape Town, Cape Town, South Africa
| | - Anthony J. Garcia-Prats
- Department of Paediatrics and Child Health, Desmond Tutu TB Centre, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Department of Pediatrics, Divisions of General Pediatrics and Adolescent Medicine and Global Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - H. Simon Schaaf
- Department of Paediatrics and Child Health, Desmond Tutu TB Centre, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Jana L. Winckler
- Department of Paediatrics and Child Health, Desmond Tutu TB Centre, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Heather Draper
- Department of Paediatrics and Child Health, Desmond Tutu TB Centre, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Jennifer Norman
- Department of Medicine, Division of Clinical Pharmacology, University of Cape Town, Cape Town, South Africa
| | - Lubbe Wiesner
- Department of Medicine, Division of Clinical Pharmacology, University of Cape Town, Cape Town, South Africa
| | - Helen McIlleron
- Department of Medicine, Division of Clinical Pharmacology, University of Cape Town, Cape Town, South Africa
| | - Paolo Denti
- Department of Medicine, Division of Clinical Pharmacology, University of Cape Town, Cape Town, South Africa
| | - Anneke C. Hesseling
- Department of Paediatrics and Child Health, Desmond Tutu TB Centre, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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HU Y, ZUO M, WANG X, WANG R, LI L, LU X, JIANG S. Pharmacokinetic interactions between the potential COVID-19 treatment drugs lopinavir/ritonavir and arbidol in rats. J Zhejiang Univ Sci B 2021; 22:599-602. [PMID: 34269012 PMCID: PMC8284091 DOI: 10.1631/jzus.b2000728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 02/21/2021] [Indexed: 11/11/2022]
Abstract
The coronavirus disease 2019 (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has occasioned worldwide alarm. Globally, the number of reported confirmed cases has exceeded 84.3 million as of this writing (January 2, 2021). Since there are no targeted therapies for COVID-19, the current focus is the repurposing of drugs approved for other uses. In some clinical trials, antiviral drugs such as remdesivir (Grein et al., 2020), lopinavir/ritonavir (LPV/r) (Cao et al., 2020), chloroquine (Gao et al., 2020), hydroxychloroquine (Gautret et al., 2020), arbidol (Wang et al., 2020), and favipiravir (Cai et al., 2020b) have shown efficacy in COVID-19 patients. LPV/r combined with arbidol, which is the basic regimen in some regional hospitals in China including Zhejiiang Province, has shown antiviral effects in COVID-19 patients (Guo et al., 2020; Xu et al., 2020). A retrospective cohort study also reported that this combination therapy showed better efficacy than LPV/r alone for the treatment of COVID-19 patients (Deng et al., 2020).
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Affiliation(s)
- Yunzhen HU
- Department of Clinical Pharmacy, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou310006, China
| | - Minjuan ZUO
- Public Service Platform for the Evaluation of Innovative Drug Property, Hangzhou311121, China
| | - Xiaojuan WANG
- Department of Clinical Pharmacy, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou310006, China
| | - Rongrong WANG
- Department of Clinical Pharmacy, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou310006, China
| | - Lu LI
- Department of Clinical Pharmacy, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou310006, China
| | - Xiaoyang LU
- Department of Clinical Pharmacy, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou310006, China
| | - Saiping JIANG
- Department of Clinical Pharmacy, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou310006, China
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von Hentig N, Angioni C, Königs C. Determination of lopinavir/ritonavir concentrations in four different oral solutions for the application of antiretroviral therapy in very young, HIV-1-infected children. South Afr J HIV Med 2021; 22:1222. [PMID: 34192069 PMCID: PMC8182455 DOI: 10.4102/sajhivmed.v22i1.1222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 03/30/2021] [Indexed: 12/03/2022] Open
Affiliation(s)
- Nils von Hentig
- Internal Medicine II, HIVCENTER, Goethe University Hospital, Frankfurt, Germany
| | - Carlo Angioni
- Institute of Clinical Pharmacology, Goethe University Hospital, Frankfurt, Germany
| | - Christoph Königs
- Department of Pediatrics and Adolescent Medicine, Goethe University Hospital, Frankfurt, Germany
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Yang J, Nikanjam M, Best BM, Pinto J, Chadwick EG, Daar ES, Havens PL, Rakhmanina N, Capparelli EV. Population Pharmacokinetics of Lopinavir/Ritonavir: Changes Across Formulations and Human Development From Infancy Through Adulthood. J Clin Pharmacol 2018; 58:1604-1617. [PMID: 30252146 PMCID: PMC6604805 DOI: 10.1002/jcph.1293] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 07/06/2018] [Indexed: 11/05/2022]
Abstract
Lopinavir/ritonavir (LPV/r) is recommended by the World Health Organization as first-line treatment for HIV-infected infants and young children. We performed a composite population pharmacokinetic (PK) analysis on LPV plasma concentration data from 6 pediatric and adult studies to determine maturation and formulation effects from infancy to adulthood. Intensive PK data were available for infants, children, adolescents, and adults (297 intensive profiles/1662 LPV concentrations). LPV PK data included 1 adult, 1 combined pediatric-adult, and 4 pediatric studies (age 6 weeks to 63 years) with 3 formulations (gel-capsule, liquid, melt-extrusion tablets). LPV concentrations were modeled using nonlinear mixed effects modeling (NONMEM v. 7.3; GloboMax, Hanover, Maryland) with a one compartment semiphysiologic model. LPV clearance was described by hepatic plasma flow (QHP ) times hepatic extraction (EH ), with EH estimated from the PK data. Volume was scaled by linear weight (WT/70)1.0 . Bioavailability was assessed separately as a function of hepatic extraction and the fraction absorbed from the gastrointestinal tract. The absorption component of bioavailability increased with age and tablet formulation. Monte Carlo simulations of the final model using current World Health Organization weight-band dosing recommendations demonstrated that participants younger than 6 months of age had a lower area under the drug concentration-time curve (94.8 vs >107.4 μg hr/mL) and minimum observed concentration of drug in blood plasma (5.0 vs > 7.1 μg/mL) values compared to older children and adults. Although World Health Organization dosing recommendations include a larger dosage (mg/m2 ) in infants to account for higher apparent clearance, they still result in low LPV concentrations in many infants younger than 6 months of age receiving the liquid formulation.
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Affiliation(s)
- Jincheng Yang
- Skaggs School of Pharmacy and Pharmaceutical Science, University of California, San Diego, California
| | - Mina Nikanjam
- Division of Hematology-Oncology, University of California San Diego, California
| | - Brookie M. Best
- Skaggs School of Pharmacy and Pharmaceutical Science, University of California, San Diego, California
- Division of Host-Microbe Systems and Therapeutics, University of California San Diego School of Medicine, San Diego, California
| | - Jorge Pinto
- Division of Immunology, School of Medicine, Federal University of Minas Gerais, Minas Gerais, Brazil
| | - Ellen G. Chadwick
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Eric S. Daar
- Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Los Angeles, California
| | - Peter L. Havens
- Division of Pediatric Infectious Diseases, Medical College of Wisconsin and Children’s Hospital of Wisconsin, Milwauke, CA
| | - Natella Rakhmanina
- Division of Pediatric Infectious Diseases, Children’s National Medical Center; The George Washington University, Washington DC
- Elizabeth Glaser Pediatric AIDS Foundation, Washington DC
| | - Edmund V. Capparelli
- Skaggs School of Pharmacy and Pharmaceutical Science, University of California, San Diego, California
- Division of Host-Microbe Systems and Therapeutics, University of California San Diego School of Medicine, San Diego, California
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Jaiswal S, Sharma A, Shukla M, Lal J. Simultaneous LC-MS-MS Determination of Lopinavir and Rifabutin in Human Plasma. J Chromatogr Sci 2018; 55:617-624. [PMID: 28334925 DOI: 10.1093/chromsci/bmx016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Accepted: 02/21/2017] [Indexed: 11/15/2022]
Abstract
Tuberculosis (TB) with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome represents the most common infectious diseases worldwide. Anti-TB drugs are used concurrently with antiretroviral drug for treatment of TB-HIV co-morbidities. Due to lower risk of interaction with protease inhibitors, rifabutin is preferred over rifampicin in treatment of HIV and TB co-morbidity. A simple and specific liquid chromatography tandem mass spectrometry method was developed for quantification of rifabutin (RBT) and lopinavir (LPV) simultaneously in human plasma. Following extraction using 60% n-hexane in ethyl acetate, the processed samples were chromatographed on a Discovery HS C18 column (5 μm, 50 × 4.6 mm, id) using mobile phase [85% acetonitrile in ammonium acetate buffer (10 mM, pH 4.5)] at a flow rate of 0.7 mL/min. Mass spectrometric detection was performed in positive electrospray ionization mode using multiple reaction monitoring (RBT, m/z 847.7 → 815.4; LPV, m/z 629.6 → 447.4). Raloxifene and phenacetin were used as internal standards for RBT and LPV, respectively. Linearity was established in the range of 1-1,000 ng/mL and 0.5-10 µg/mL (R2 ≥ 0.99) for RBT and LPV, respectively. The recovery of LPV and RBT were always >90 and >50%, respectively. The precisions and accuracies were well within the acceptable limits of variation.
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Affiliation(s)
- Swati Jaiswal
- Pharmacokinetics & Metabolism Division, CSIR-Central Drug Research Institute, Sector 10, Jankipuram Extension, Sitapur Road, Lucknow 226031, India.,Academy of Scientific and Innovative Research, Mathura Road, New Delhi 110 025, India
| | - Abhisheak Sharma
- Pharmacokinetics & Metabolism Division, CSIR-Central Drug Research Institute, Sector 10, Jankipuram Extension, Sitapur Road, Lucknow 226031, India.,Academy of Scientific and Innovative Research, Mathura Road, New Delhi 110 025, India
| | - Mahendra Shukla
- Pharmacokinetics & Metabolism Division, CSIR-Central Drug Research Institute, Sector 10, Jankipuram Extension, Sitapur Road, Lucknow 226031, India.,Academy of Scientific and Innovative Research, Mathura Road, New Delhi 110 025, India
| | - Jawahar Lal
- Pharmacokinetics & Metabolism Division, CSIR-Central Drug Research Institute, Sector 10, Jankipuram Extension, Sitapur Road, Lucknow 226031, India.,Academy of Scientific and Innovative Research, Mathura Road, New Delhi 110 025, India
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Pharmacokinetics and Drug-Drug Interactions of Lopinavir-Ritonavir Administered with First- and Second-Line Antituberculosis Drugs in HIV-Infected Children Treated for Multidrug-Resistant Tuberculosis. Antimicrob Agents Chemother 2018; 62:AAC.00420-17. [PMID: 29133558 DOI: 10.1128/aac.00420-17] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 10/13/2017] [Indexed: 11/20/2022] Open
Abstract
Lopinavir-ritonavir forms the backbone of current first-line antiretroviral regimens in young HIV-infected children. As multidrug-resistant (MDR) tuberculosis (TB) frequently occurs in young children in high-burden TB settings, it is important to identify potential interactions between MDR-TB treatment and lopinavir-ritonavir. We describe the pharmacokinetics of and potential drug-drug interactions between lopinavir-ritonavir and drugs routinely used for MDR-TB treatment in HIV-infected children. A combined population pharmacokinetic model was developed to jointly describe the pharmacokinetics of lopinavir and ritonavir in 32 HIV-infected children (16 with MDR-TB receiving treatment with combinations of high-dose isoniazid, pyrazinamide, ethambutol, ethionamide, terizidone, a fluoroquinolone, and amikacin and 16 without TB) who were established on a lopinavir-ritonavir-containing antiretroviral regimen. One-compartment models with first-order absorption and elimination for both lopinavir and ritonavir were combined into an integrated model. The dynamic inhibitory effect of the ritonavir concentration on lopinavir clearance was described using a maximum inhibition model. Even after adjustment for the effect of body weight with allometric scaling, a large variability in lopinavir and ritonavir exposure, together with strong correlations between the pharmacokinetic parameters of lopinavir and ritonavir, was detected. MDR-TB treatment did not have a significant effect on the bioavailability, clearance, or absorption rate constants of lopinavir or ritonavir. Most children (81% of children with MDR-TB, 88% of controls) achieved therapeutic lopinavir trough concentrations (>1 mg/liter). The coadministration of lopinavir-ritonavir with drugs routinely used for the treatment of MDR-TB was found to have no significant effect on the key pharmacokinetic parameters of lopinavir or ritonavir. These findings should be considered in the context of the large interpatient variability found in the present study and the study's modest sample size.
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Clarke DF, Penazzato M, Capparelli E, Cressey TR, Siberry G, Sugandhi N, Mirochnick M. Prevention and treatment of HIV infection in neonates: evidence base for existing WHO dosing recommendations and implementation considerations. Expert Rev Clin Pharmacol 2017; 11:83-93. [PMID: 29039686 DOI: 10.1080/17512433.2018.1393331] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Antiretroviral drugs are used in neonates for prevention and treatment of HIV infection. Use of antiretrovirals to prevent perinatal HIV transmission is well established. Early identification of neonates infected with HIV and rapid initiation of combination antiretroviral treatment during the neonatal period is now recommended by WHO and DHHS. However, few antiretrovirals are available in formulations suitable for neonates and there are limited safety and pharmacokinetic data for most antiretrovirals in neonates. Areas covered: We summarize existing neonatal antiretroviral safety and pharmacokinetic information and discuss implementation considerations for programs providing antiretrovirals to neonates and young infants. Expert commentary: Antiretrovirals currently recommended by WHO for use in neonates are zidovudine, lamivudine, lopinavir/ritonavir, nevirapine, and raltegravir. Significant implementation challenges exist to the widespread use of these antiretrovirals in neonates. Optimal, feasible treatment of HIV-exposed and HIV-infected newborns will require development of practical neonatal dosage forms and their study in neonates for a wide range of antiretrovirals.
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Affiliation(s)
- Diana F Clarke
- a Department of Pediatric Infectious Diseases , Boston Medical Center , Boston , MA , USA.,b Department of Pediatrics , Boston University School of Medicine , Boston , MA , USA
| | - Martina Penazzato
- c Department of HIV/AIDS , World Health Organization , Geneva , Switzerland
| | - Edmund Capparelli
- d Skaggs School of Pharmacy and Pharmaceutical Sciences , University of California San Diego , La Jolla , CA , USA
| | - Tim R Cressey
- e PHPT-IRD (UMI 174), Faculty of Associated Medical Sciences , Chiang Mai University , Chiang Mai , Thailand.,f Department of Immunology & Infectious Diseases , Harvard T.H. Chan School of Public Health , Boston , MA , USA.,g Department of Molecular & Clinical Pharmacology , University of Liverpool , Liverpool , UK
| | - George Siberry
- h Office of the Global AIDS , U.S. Department of State , Washington , DC , USA
| | | | - Mark Mirochnick
- b Department of Pediatrics , Boston University School of Medicine , Boston , MA , USA
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Danielak D, Twardosz J, Kasprzyk A, Wachowiak J, Kałwak K, Główka F. Population pharmacokinetics of treosulfan and development of a limited sampling strategy in children prior to hematopoietic stem cell transplantation. Eur J Clin Pharmacol 2017; 74:79-89. [PMID: 28975382 PMCID: PMC5748442 DOI: 10.1007/s00228-017-2344-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Accepted: 09/26/2017] [Indexed: 12/03/2022]
Abstract
Purpose There is an increasing interest in use of treosulfan (TREO), a structural analogue of busulfan, as an agent in conditioning regimens prior to hematopoietic stem cell transplantation (HSCT), both in pediatric and adult populations. The aim of this study was to develop a population pharmacokinetic model and to establish limited sampling strategies (LSSs) enabling accurate estimation of exposure to this drug. Methods The study included 15 pediatric patients with malignant and non-malignant diseases, undergoing conditioning regimens prior to HSCT including TREO administered as a 1 h or 2 h infusion at daily doses of 10, 12, or 14 g/m2. A population pharmacokinetic model was developed by means of non-linear mixed-effect modeling approach in Monolix® software. Multivariate regression analysis and Bayesian method were used to develop 2- and 3-point strategies for estimation of exposure to TREO. Results Pharmacokinetics of TREO was best described with a two-compartmental linear model with proportional residual error. Following sampling schedules allowed accurate estimation of exposure to TREO: 1 h and 6 h or 1 h, 2 h, and 6 h for a TREO dose 12 g/m2 in a 1 h infusion, or at 2 h and 6 h or 2 h, 4 h, and 8 h for a TREO dose of 12 g/m2 and 14 g/m2 in a 2 h infusion. Conclusions A two-compartmental population pharmacokinetic model of TREO was developed and successfully used to establish 2- and 3-point LSSs for accurate and precise estimation of TREO AUC0→∞.
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Affiliation(s)
- Dorota Danielak
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, Święcickiego 6 St, 60-781, Poznań, Poland.
| | - Jadwiga Twardosz
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, Święcickiego 6 St, 60-781, Poznań, Poland
| | - Anna Kasprzyk
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, Święcickiego 6 St, 60-781, Poznań, Poland
| | - Jacek Wachowiak
- Department of Pediatric Hematology, Oncology and Transplantology, Poznan University of Medical Sciences, Poznań, Poland
| | - Krzysztof Kałwak
- Department of Pediatric Hematology, Oncology and Bone Marrow Transplantation, Wroclaw Medical University, Wrocław, Poland
| | - Franciszek Główka
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, Święcickiego 6 St, 60-781, Poznań, Poland
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10
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Madelain V, Le MP, Champenois K, Charpentier C, Landman R, Joly V, Yeni P, Descamps D, Yazdanpanah Y, Peytavin G. Impact of obesity on antiretroviral pharmacokinetics and immuno-virological response in HIV-infected patients: a case-control study. J Antimicrob Chemother 2017; 72:1137-1146. [PMID: 28065890 DOI: 10.1093/jac/dkw527] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 11/07/2016] [Indexed: 12/11/2022] Open
Abstract
Background Obesity has high prevalence among HIV-infected patients. Increased adipose tissue mass affects the pharmacokinetics of numerous drugs, but few data are available for antiretroviral drugs. Objectives In this study we aimed to explore the pharmacokinetics of antiretroviral drugs and the immuno-virological response in obese patients with HIV infection. Patients and methods We examined data from 2009 to 2012 in our hospital's database for HIV-1-infected patients who received an antiretroviral drug (abacavir, emtricitabine, lamivudine, tenofovir, efavirenz, etravirine, nevirapine, atazanavir/ritonavir, darunavir/ritonavir, lopinavir/ritonavir or raltegravir). Obese patients were defined as those with BMI ≥30 kg/m 2 and normal-weight patients as those with BMI 19-25 kg/m 2 . Plasma concentrations ( C 12/24 ) were compared for each antiretroviral drug using a Mann-Whitney test. Suboptimal dosing and virological outcome were assessed by logistic regression, adjusting on covariates. Results We enrolled 291 obese and 196 normal-weight patients. Among the 12 analysed antiretroviral drugs, tenofovir, efavirenz and lopinavir C 12 values were significantly lower in obese than normal-weight patients: 66 versus 86 ng/mL, 1498 versus 2034 ng/mL and 4595 versus 6420 ng/mL, respectively ( P < 0.001). Antiretroviral drug C 12/24 values were more frequently below efficacy thresholds for obese than for normal-weight patients after adjustment for other covariates ( P < 0.001). Although obese patients showed a higher CD4 count than normal-weight patients (510 versus 444 cells/mm 3 , P < 0.001), the groups did not differ in virological failure rate. Conclusions This study highlights the impact of obesity on antiretroviral drug plasma exposure, but identifies no consequence of this suboptimal exposure on the immuno-virological control in this population.
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Affiliation(s)
- Vincent Madelain
- IAME, UMR 1137, Université Paris Diderot, Sorbonne Paris Cité and INSERM, Paris F-75018, France.,AP-HP, Hôpital Bichat-Claude Bernard, Laboratoire de Pharmaco-Toxicologie, Paris F-75018, France
| | - Minh P Le
- IAME, UMR 1137, Université Paris Diderot, Sorbonne Paris Cité and INSERM, Paris F-75018, France.,AP-HP, Hôpital Bichat-Claude Bernard, Laboratoire de Pharmaco-Toxicologie, Paris F-75018, France
| | - Karen Champenois
- IAME, UMR 1137, Université Paris Diderot, Sorbonne Paris Cité and INSERM, Paris F-75018, France
| | - Charlotte Charpentier
- IAME, UMR 1137, Université Paris Diderot, Sorbonne Paris Cité and INSERM, Paris F-75018, France.,AP-HP, Hôpital Bichat-Claude Bernard, Laboratoire de Virologie, Paris F-75018, France
| | - Roland Landman
- IAME, UMR 1137, Université Paris Diderot, Sorbonne Paris Cité and INSERM, Paris F-75018, France.,AP-HP, Hôpital Bichat-Claude Bernard, Service de Maladies Infectieuses et Tropicales, Paris F-75018, France
| | - Veronique Joly
- IAME, UMR 1137, Université Paris Diderot, Sorbonne Paris Cité and INSERM, Paris F-75018, France.,AP-HP, Hôpital Bichat-Claude Bernard, Service de Maladies Infectieuses et Tropicales, Paris F-75018, France
| | - Patrick Yeni
- IAME, UMR 1137, Université Paris Diderot, Sorbonne Paris Cité and INSERM, Paris F-75018, France.,AP-HP, Hôpital Bichat-Claude Bernard, Service de Maladies Infectieuses et Tropicales, Paris F-75018, France
| | - Diane Descamps
- IAME, UMR 1137, Université Paris Diderot, Sorbonne Paris Cité and INSERM, Paris F-75018, France.,AP-HP, Hôpital Bichat-Claude Bernard, Laboratoire de Virologie, Paris F-75018, France
| | - Yazdan Yazdanpanah
- IAME, UMR 1137, Université Paris Diderot, Sorbonne Paris Cité and INSERM, Paris F-75018, France.,AP-HP, Hôpital Bichat-Claude Bernard, Service de Maladies Infectieuses et Tropicales, Paris F-75018, France
| | - Gilles Peytavin
- IAME, UMR 1137, Université Paris Diderot, Sorbonne Paris Cité and INSERM, Paris F-75018, France.,AP-HP, Hôpital Bichat-Claude Bernard, Laboratoire de Pharmaco-Toxicologie, Paris F-75018, France
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11
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Punyawudho B, Singkham N, Thammajaruk N, Dalodom T, Kerr SJ, Burger DM, Ruxrungtham K. Therapeutic drug monitoring of antiretroviral drugs in HIV-infected patients. Expert Rev Clin Pharmacol 2016; 9:1583-1595. [PMID: 27626677 DOI: 10.1080/17512433.2016.1235972] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Therapeutic drug monitoring (TDM) may be beneficial when applied to antiretroviral (ARV). Even though TDM can be a valuable strategy in HIV management, its role remains controversial. Areas covered: This review provides a comprehensive update on important issues relating to TDM of ARV drugs in HIV-infected patients. Articles from PubMed with keywords relevant to each topic section were reviewed. Search strategies limited to articles published in English. Expert commentary: There is evidence supporting the use of TDM in HIV treatment. However, some limitations need to be considered. The evidence supporting the use of routine TDM for all patients is limited, as it is not clear that this strategy offers any advantages over TDM for selected indications. Selected groups of patients including patients with physiological changes, patients with drug-drug interactions or toxicity, and the elderly could potentially benefit from TDM, as optimized dosing is challenging in these populations.
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Affiliation(s)
- Baralee Punyawudho
- a Department of Pharmaceutical Care, Faculty of Pharmacy , Chiang Mai University , Chiang Mai , Thailand
| | - Noppaket Singkham
- a Department of Pharmaceutical Care, Faculty of Pharmacy , Chiang Mai University , Chiang Mai , Thailand
| | | | - Theera Dalodom
- b HIV-NAT , Thai Red Cross AIDS Research Centre , Bangkok , Thailand
| | - Stephen J Kerr
- b HIV-NAT , Thai Red Cross AIDS Research Centre , Bangkok , Thailand.,c The Kirby Institute, University of New South Wales , Sydney , Australia.,d Department of Global Health, Academic Medical Center , University of Amsterdam, Amsterdam Institute for Global Health and Development , Amsterdam , The Netherlands
| | - David M Burger
- e Radbound University Medical Center , Nijmegen , The Netherlands
| | - Kiat Ruxrungtham
- b HIV-NAT , Thai Red Cross AIDS Research Centre , Bangkok , Thailand.,f Faculty of Medicine , Chulalongkorn University , Bangkok , Thailand
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12
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de Ruiter A, Taylor GP, Clayden P, Dhar J, Gandhi K, Gilleece Y, Harding K, Hay P, Kennedy J, Low-Beer N, Lyall H, Palfreeman A, O'Shea S, Tookey P, Tosswill J, Welch S, Wilkins E. British HIV Association guidelines for the management of HIV infection in pregnant women 2012 (2014 interim review). HIV Med 2015; 15 Suppl 4:1-77. [PMID: 25604045 DOI: 10.1111/hiv.12185] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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13
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Bartelink IH, Savic RM, Dorsey G, Ruel T, Gingrich D, Scherpbier HJ, Capparelli E, Jullien V, Young SL, Achan J, Plenty A, Charlebois E, Kamya M, Havlir D, Aweeka F. The effect of malnutrition on the pharmacokinetics and virologic outcomes of lopinavir, efavirenz and nevirapine in food insecure HIV-infected children in Tororo, Uganda. Pediatr Infect Dis J 2015; 34:e63-70. [PMID: 25742090 PMCID: PMC4351793 DOI: 10.1097/inf.0000000000000603] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Malnutrition may impact the pharmacokinetics (PKs) of antiretroviral medications and virologic responses in HIV-infected children. The authors therefore evaluated the PK of nevirapine (NVP), efavirenz (EFV) and lopinavir (LPV) in associations with nutritional status in a cohort of HIV-infected Ugandan children. METHODS Sparse dried blood spot samples from Ugandan children were used to estimate plasma concentrations. Historical PK data from children from 3 resource-rich countries (RRC) were utilized to develop the PK models. RESULTS Concentrations in 330 dried blood spot from 163 Ugandan children aged 0.7-7 years were analyzed in reference to plasma PK data (1189 samples) from 204 children from RRC aged 0.5-12 years. Among Ugandan children, 48% was malnourished (underweight, thin or stunted). Compared to RRC, Ugandan children exhibited reduced bioavailability of EFV and LPV; 11% (P=0.045) and 18% (P=0.008), respectively. In contrast, NVP bioavailability was 46% higher in Ugandan children (P<0.001) with a trend toward greater bioavailability when malnourished. Children receiving LPV, EFV or NVP had comparable risk of virologic failure. Among children on NVP, low height and weight for age Z scores were associated with reduced risk of virologic failure (P=0.034, P=0.068, respectively). CONCLUSIONS Ugandan children demonstrated lower EFV and LPV and higher NVP exposure compared to children in RRC, perhaps reflecting the consequence of malnutrition on bioavailability. In children receiving NVP, the relation between exposure, malnutrition and outcome turned out to be marginally significant. Further investigations are warranted using more intensive PK measurements and adequate adherence assessments, to further assess causes of virologic failure in Ugandan children.
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Affiliation(s)
- Imke H. Bartelink
- Department of Clinical Pharmacy, University of California, San Francisco, California, United States of America
- Department of Bioengineering & Therapeutic Sciences, University of California, San Francisco, California, United States of America
| | - Rada M. Savic
- Department of Bioengineering & Therapeutic Sciences, University of California, San Francisco, California, United States of America
| | - Grant Dorsey
- Department of Medicine, University of California, San Francisco, California, United States of America
| | - Theodore Ruel
- Department of Pediatrics, University of California, San Francisco, California, United States of America
| | - David Gingrich
- Department of Clinical Pharmacy, University of California, San Francisco, California, United States of America
| | - Henriette J. Scherpbier
- Department of Pediatric Immunology and Infectious Diseases, Emma Children’s Hospital AMC, The Netherlands
| | - Edmund Capparelli
- University of California San Diego, La Jolla, California, United States of America
| | - Vincent Jullien
- Department of Pharmacology, Hôpital Européen Georges Pompidou, Paris Descartes, France
| | - Sera L. Young
- Division of Nutritional Sciences, Cornell University, Ithaca, New York, United States of America
| | - Jane Achan
- Department of Pediatrics and Child Health, Makerere University Kampala, Uganda
| | - Albert Plenty
- Center for AIDS Prevention Studies, University of California, San Francisco, California, United States of America
| | - Edwin Charlebois
- Center for AIDS Prevention Studies, University of California, San Francisco, California, United States of America
| | - Moses Kamya
- Department of Medicine, Makerere University Kampala, Uganda
| | - Diane Havlir
- Department of Medicine, University of California, San Francisco, California, United States of America
| | - Francesca Aweeka
- Department of Clinical Pharmacy, University of California, San Francisco, California, United States of America
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14
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Kariyawasam D, Simon A, Laborde K, Parat S, Souchon PF, Frange P, Blanche S, Polak M. Adrenal enzyme impairment in neonates and adolescents treated with ritonavir and protease inhibitors for HIV exposure or infection. Horm Res Paediatr 2015; 81:226-31. [PMID: 24577112 DOI: 10.1159/000356916] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2013] [Accepted: 10/11/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Human deficiency virus (HIV) protease inhibitors (PIs) are widely used drugs whose effects are pharmacologically enhanced by ritonavir, a potent cytochrome P450 inhibitor. We reported previously that prophylactic postnatal ritonavir-PI therapy in HIV-exposed neonates was associated with increases in plasma 17-hydroxyprogesterone (17-OHP) and dehydroepiandrosterone sulfate (DHEA-S). AIMS To further investigate adrenal function in neonates and adolescents given ritonavir-PI. METHODS Adrenal function was assessed prospectively in 3 HIV-exposed neonates given short-term prophylactic treatment and 3 HIV-infected adolescents given long-term treatment. Plasma cortisol, 17-OHP, 17-OH-pregnenolone, DHEA-S, and androstenedione were measured before and after ACTH administration. RESULTS None of the patients had clinical signs of adrenal dysfunction. The only neonate exposed to ritonavir-PI in utero had up to 3-fold increases in plasma 17-OHP. Increases in 17-OH-pregnenolone of up to 3.1-fold were noted in 4 of the 6 patients, and all 6 patients had elevations in DHEA-S (up to 20.4-fold increase) and/or DHEA (up to 4.7-fold) and/or androstenedione (up to 5.2-fold). All these parameters improved after treatment completion. CONCLUSION Neonates and adolescents given ritonavir-PI exhibit a similar adrenal dysfunction profile consistent with an impact on multiple adrenal enzymes. These abnormalities require evaluation, given the potentially long exposure times.
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Affiliation(s)
- D Kariyawasam
- Pediatric Endocrinology Gynecology and Diabetology Unit, Assistance Publique-Hôpitaux de Paris (AP-HP) and IMAGINE Institute affiliate, Paris, France
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15
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Bouazza N, Foissac F, Fauchet F, Burger D, Kiechel JR, Treluyer JM, Capparelli EV, Lallemant M, Urien S. Lopinavir/ritonavir plus lamivudine and abacavir or zidovudine dose ratios for paediatric fixed-dose combinations. Antivir Ther 2014; 20:225-33. [PMID: 25279808 DOI: 10.3851/imp2876] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Lopinavir/ritonavir (LPV/r) is available in a liquid formulation that is far from ideal for treatment of children in resource-poor settings. Flexible, low-cost, solid, oral fixed-dose combinations (FDC) of LPV/r with nucleoside reverse transcriptase inhibitors (LPV/r/abacavir [ABC]/lamivudine [3TC] and LPV/r/zidovudine [ZDV]/3TC) are needed to improve both management and adherence of children. This work aimed to develop appropriate drug ratios and dosing for each FDC. METHODS Data from 25 combined datasets included therapeutic drug monitoring and clinical studies from IMPAACT and PENTA. Population pharmacokinetic analyses were performed using Monolix. Monte-Carlo simulations of WHO and FDA dosing recommendations were performed to assess their ability to provide optimal exposure in children weighing 4 to 25 kg based on consensus plasma targets. The LPV/r:3TC:ZDV(ABC) dose ratios were 2.67:1:2(2), respectively. RESULTS Using WHO dosage, LPV efficacy target was reached in all weight bands. Given the recommended drug ratios, the dosage for the 4-5.9 kg weight band (LPV/ZDV: 120/90 mg twice daily [bid]) showed more than 20% of subjects had ZDV levels at high risk of neutropenia. Reducing the LPV/ZDV dose to 80/60 mg bid decreased frequency of high ZDV concentrations but retained the LPV efficacy criteria. CONCLUSIONS This defined a flexible and simple FDC containing 40 mg LPV, 10 mg ritonavir, 15 mg 3TC and 30 mg ABC or ZDV. According to the weight bands defined by WHO, 4-5.9 kg, 6-9.9 kg, 10-13.9 kg, 14-19.9 kg, 20-24.9 kg, therapeutic doses would be 2, 3, 4, 5 or 6 individual units administered by oral route bid.
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Affiliation(s)
- Naïm Bouazza
- EA 7323, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
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16
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López Aspiroz E, Santos Buelga D, Cabrera Figueroa SE, Valverde Merino MDLP, Cordero Sánchez M, Domínguez-Gil Hurlé A, Carracedo Á, García Sánchez MJ. Population pharmacokinetic/pharmacogenetic model of lopinavir/ritonavir in HIV-infected patients. Per Med 2014; 11:693-704. [PMID: 29764054 DOI: 10.2217/pme.14.58] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
AIM This study aims to develop a population pharmacokinetic/pharmacogenetic model for lopinavir/ritonavir (LPV/r) in European HIV-infected patients. MATERIALS & METHODS A total of 693 LPV/r plasma concentrations were assessed and 15 single-nucleotide polymorphisms were genotyped. The population pharmacokinetic/pharmacogenetic model was created using a nonlinear mixed-effect approach (NONMEM® v.7.2.0., ICON Development Solutions, Dublin, Ireland). RESULTS Covariates significantly related to LPV/r apparent clearance (CL/F) were ritonavir trough concentration (RTC), BMI, high-density lipoprotein cholesterol (HDL-C) and certain single-nucleotide polymorphisms in genes encoding for metabolizing enzymes, which are representable as follows: CL/F = (0.216BMI + 0.0125HDL-C) × 0.713RTC × 1.26rs28371764[C/T] × 0.528rs6945984[C/C] × 0.302 CYP3A4[1461insA/del] Conclusion: The LPV/r standard dose appears to be appropriate for the rs28371764[C/T] genotype. However, lower doses should be recommended for the rs6945984[C/C] and CYP3A4[1461insA/del] genotypes and even for those patients without any of these variants, as the standard dose seems to be higher than that which is required in order to achieve therapeutic levels.
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Affiliation(s)
- Elena López Aspiroz
- Pharmacy Service, University Hospital of Salamanca, Paseo de San Vicente 58, 37007 Salamanca, Spain
| | - Dolores Santos Buelga
- Department of Pharmacy & Pharmaceutical Technology, Faculty of Pharmacy, University of Salamanca, Salamanca, Spain
| | - Salvador Enrique Cabrera Figueroa
- Pharmacy Service, University Hospital of Salamanca, Paseo de San Vicente 58, 37007 Salamanca, Spain.,Instituto de Farmacia, Facultad de Ciencias, Universidad Austral de Chile, Valdivia, Chile
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- Tormes Team: Carmen Bustos Bernal, Aurelio Fuertes Martín, María Jesús Hernández Arroyo, Alicia Iglesias Gómez and Guillermo Luna Rodrigo
| | | | - Alfonso Domínguez-Gil Hurlé
- Pharmacy Service, University Hospital of Salamanca, Paseo de San Vicente 58, 37007 Salamanca, Spain.,Department of Pharmacy & Pharmaceutical Technology, Faculty of Pharmacy, University of Salamanca, Salamanca, Spain
| | - Ángel Carracedo
- Grupo de Medicina Xenómica. Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Universidad de Santiago de Compostela, Spain.,Fundación Pública Galega de Medicina Xenómica, Instituto de Investigación Sanitaria de Santiago de Compostela (IDIS), SERGAS (Servicio Galega de Saude), Santiago de Compostela, Spain.,Center of Excellence in Genomic Medicine Research, King Abdulaziz University, Jeddah, Saudi Arabia
| | - María José García Sánchez
- Department of Pharmacy & Pharmaceutical Technology, Faculty of Pharmacy, University of Salamanca, Salamanca, Spain
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17
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Prinapori R, Rosso R, Di Biagio A, Miletich F, Furfaro E, Taramasso L, Ginocchio F, Giacomet V, Nulvesu L, Sormani MP, Schiavetti I, Signori A, De Hoffer L, Viscoli C. Pharmacokinetics of lopinavir determined with an ELISA test in youths with perinatally acquired HIV. Indian J Pediatr 2014; 81:856-60. [PMID: 24014186 DOI: 10.1007/s12098-013-1198-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2013] [Accepted: 07/24/2013] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To investigate the plasma levels of lopinavir by enzyme-linked immunosorbent assay (ELISA) in a cohort of patients who were vertically infected with human immunodeficiency virus 1 (HIV). METHODS Plasma levels of lopinavir (Cmin) were determined by ELISA test in patients treated with lopinavir/ritonavir-based combined antiretroviral therapy who had achieved virological response after 4 wk of therapy. Reference lopinavir concentrations were Cmin 1-8 μg/mL. Correlation between lopinavir plasma concentration and continuous variables was evaluated by mean of Pearson correlation coefficient. Differences in lopinavir (LPV) concentration for binary categorical variables were assessed by Mann-Whitney test, while for variables with more than two categories Kruskal-Wallis test was used. RESULTS Thirty-four patients were enrolled; median age was 133 mo (15-265). The median lopinavir dose tested was 383.5 mg/kg (IQR: 266.6-400 mg/kg), with a median plasma concentration of 8.8 μg/mL (IQR: 5-14 μg/mL). Lopinavir Cmin was <1 μg/mL in only one sample (2.9 %), while 14 samples had Cmin between 1 and 8 μg/mL (41.2 %) and 19 (55.9 %) > 8 μg/mL. No significant correlations were found between plasma concentrations of lopinavir and the continuous variables considered in the study. A negative but, not completely significant, correlation was found between plasma drug concentration and body mass index (r = -0.29; p = 0.09). CONCLUSIONS The use of a simple and relatively cost-effective methodology might render therapeutic drug monitoring (TDM) appeal in the daily clinical practice.
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Affiliation(s)
- Roberta Prinapori
- Infectious Diseases Clinic, San Martino Hospital, University of Genoa, Genoa, Italy
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18
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Bastiaans DET, Cressey TR, Vromans H, Burger DM. The role of formulation on the pharmacokinetics of antiretroviral drugs. Expert Opin Drug Metab Toxicol 2014; 10:1019-37. [DOI: 10.1517/17425255.2014.925879] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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19
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Pharmacokinetics of pediatric lopinavir/ritonavir tablets in children when administered twice daily according to FDA weight bands. Pediatr Infect Dis J 2014; 33:301-5. [PMID: 24356253 DOI: 10.1097/inf.0000000000000014] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Lopinavir/ritonavir (LPV/r) pediatric tablets (100/25 mg) are approved by the United States Food and Drug Administration (FDA) and European Medicines Agency (EMA) as part of combination antiretroviral therapy. Dosing is based on body weight bands or body surface area under FDA approval and only body surface area by the EMA. This can lead to a different recommended dose. In addition, weight band-based dosing has not been formally studied in the target population. We evaluated the pharmacokinetics (PK) of LPV/r in children, administered twice daily according to the FDA weight bands, using pediatric tablets. METHODS Fifty-three HIV-infected children were included in the PK substudy of the Paediatric European Network for the Treatment of AIDS 18 trial (KONCERT). In this study, children were randomized to receive LPV/r twice or once daily, according to FDA weight bands. A PK assessment was performed in 17, 16 and 20 children in the 15-25 kg, ≥ 25-35 kg and >35 kg weight band, respectively, while children took the tablets twice daily. Rich sampling was performed, and PK parameters were calculated by noncompartmental analysis. Given the high percentage of Asian children, it was also tested whether there was a difference in PK parameters between Asian and non-Asian children. RESULTS For the total group, LPV geometric mean AUC0-12, Cmax and C12 were 106.9 h × mg/L, 12.0 mg/L and 4.9 mg/L, respectively. There were no significant differences in LPV PK parameters between the weight bands. In addition, weight was not found to be associated with variability in Cmax, C12 or AUC0-12 for the LPV PK parameters. CONCLUSIONS FDA weight band-based dosing recommendations provide adequate exposure to LPV when using LPV/r pediatric tablets.
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20
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Agwu AL, Fairlie L. Antiretroviral treatment, management challenges and outcomes in perinatally HIV-infected adolescents. J Int AIDS Soc 2013; 16:18579. [PMID: 23782477 PMCID: PMC3687074 DOI: 10.7448/ias.16.1.18579] [Citation(s) in RCA: 139] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Accepted: 04/17/2013] [Indexed: 02/06/2023] Open
Abstract
Three decades into the HIV/AIDS epidemic there is a growing cohort of perinatally HIV-infected adolescents globally. Their survival into adolescence and beyond represent one of the major successes in the battle against the disease that has claimed the lives of millions of children. This population is diverse and there are unique issues related to antiretroviral treatment and management. Drawing from the literature and experience, this paper discusses several broad areas related to antiretroviral management, including: 1) diverse presentation of HIV, (2) use of combination antiretroviral therapy including in the setting of co-morbidities and rapid growth and development, (3) challenges of cART, including nonadherence, resistance, and management of the highly treatment-experienced adolescent patient, (4) additional unique concerns and management issues related to PHIV-infected adolescents, including the consequences of longterm inflammation, risk of transmission, and transitions to adult care. In each section, the experience in both resource-rich and limited settings are discussed with the aim of highlighting the differences and importantly the similarities, to share lessons learnt and provide insight into the multi-faceted approaches that may be needed to address the challenges faced by this unique and resilient population.
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Affiliation(s)
- Allison L Agwu
- Division of Paediatric Infectious Diseases, Department of Paediatrics, Johns Hopkins School of Medicine Baltimore, MD, USA.
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21
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Zhang C, McIlleron H, Ren Y, van der Walt JS, Karlsson MO, Simonsson USH, Denti P. Population pharmacokinetics of lopinavir and ritonavir in combination with rifampicin-based antitubercular treatment in HIV-infected children. Antivir Ther 2013; 17:25-33. [PMID: 22267466 DOI: 10.3851/imp1915] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND The preferred antiretroviral regimen for young children previously exposed to non-nucleoside reverse transcriptase inhibitors is lopinavir/ritonavir plus two nucleoside reverse transcriptase inhibitors. Rifampicin-based antitubercular treatment reduces lopinavir concentrations. Adding extra ritonavir to lopinavir/ritonavir overcomes the effect of rifampicin, however this approach is not feasible in many settings. METHODS We developed an integrated population model describing lopinavir and ritonavir pharmacokinetics to predict lopinavir/ritonavir (4:1) doses achieving target lopinavir exposures in children treated for tuberculosis. The model included data from 15 children given 'super-boosted' lopinavir (lopinavir/ritonavir =1:1) and 20 children given twice the standard dose of lopinavir/ritonavir every 12 h during antitubercular treatment, and from children given standard lopinavir/ritonavir doses every 12 h (39 without tuberculosis and 11 sampled again after antitubercular treatment). RESULTS A one-compartment model with first-order absorption and elimination best described the pharmacokinetics of lopinavir and a one-compartment model with transit absorption compartments described ritonavir pharmacokinetics. The dynamic influence of ritonavir concentration on lopinavir oral clearance was modelled as direct inhibition with an E(max) model. Antitubercular treatment reduced the oral bioavailability of lopinavir by 77% in children receiving twice usual lopinavir/ritonavir doses and increased ritonavir clearance by 50%. Simulations predicted that respective 27, 21, 20 and 18 mg/kg 8-hourly doses of lopinavir (in lopinavir/ritonavir, 4:1) maintains lopinavir concentrations >1 mg/l in at least 95% of children weighing 3-5.9, 6-9.9, 10-13.9 and 14-19.9 kg. CONCLUSIONS The model describing the interactions between lopinavir, ritonavir and rifampicin in young children predicted feasible 8-hourly doses of lopinavir/ritonavir resulting in therapeutic lopinavir concentrations during antitubercular treatment.
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Affiliation(s)
- Chao Zhang
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
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22
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Turkova A, Webb RH, Lyall H. When to start, what to start and other treatment controversies in pediatric HIV infection. Paediatr Drugs 2012; 14:361-76. [PMID: 23013459 DOI: 10.2165/11599640-000000000-00000] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Over the last decade there have been dramatic changes in the management of pediatric HIV infection. Whilst observational studies and several randomized control trials (RCTs) have addressed some questions about when to start antiretroviral therapy (ART) in children and what antiretrovirals to start, many others remain unanswered. In infants, early initiation of ART greatly reduces mortality and disease progression. Treatment guidelines now recommend ART in all infants younger than 1 or 2 years of age depending on geographical setting. In children >1 year of age, US, European (Paediatric European Network for Treatment of AIDS; PENTA) and WHO guidelines differ and debate is ongoing. Recent data from an RCT in Thailand in children with moderate immune suppression indicate that it is safe to monitor asymptomatic children closely without initiating ART, although earlier treatment was associated with improved growth. Untreated HIV progression in children aged over 5 years is similar to that in adults, and traditionally adult treatment thresholds are applied. Recent adult observational and modeling studies showed a survival advantage and reduction of age-associated complications with early treatment. The current US guidelines have lowered CD4+ cell count thresholds for ART initiation for children aged >5 years to 500 cells/mm3. Co-infections influence the choice of drugs and the timing of starting ART. Drug interactions, overlapping toxicities and adherence problems secondary to increased pill burden are important issues. Rapid changes in the pharmacokinetics of antiretrovirals in the first years of life, limited pharmacokinetic data in children and genetic variation in metabolism of many antiretrovirals make correct dosing difficult. Adherence should always be addressed prior to starting ART or switching regimens. The initial ART regimen depends on previous exposure, including perinatal administration for prevention of mother to child transmission (PMTCT), adherence, co-infections, drug availability and licensing. A European cohort study in infants indicated that treatment with four drugs produced superior virologic suppression and immune recovery. Protease inhibitor (PI)-based ART has the advantage of a high barrier to viral resistance. A recent RCT conducted in several African countries showed PI-based ART to be advantageous in children aged <3 years compared with nevirapine-based ART irrespective of previous nevirapine exposure. Another trial in older children from resource rich settings showed both regimens were equally effective. Treatment interruption remains a controversial issue in children, but one study in Europe demonstrated no short-term detrimental effects. ART in children is a rapidly evolving area with many new antiretrovirals being developed and undergoing trials. The aim of ART has shifted from avoiding mortality and morbidity to achieving a normal life expectancy and quality of life, minimizing toxicities and preventing early cancers and age-related illnesses.
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Affiliation(s)
- Anna Turkova
- Department of Paediatric Infectious Diseases, St Mary's Hospital, Imperial College NHS Trust, London, UK
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Abstract
PURPOSE OF REVIEW The pharmacokinetics of antiretroviral drugs are highly variable among HIV-infected children. This review describes pharmacokinetic processes in children and recent pharmacokinetic data in children with HIV. The general lack of pharmacokinetic data and the potential role of therapeutic drug monitoring are discussed. RECENT FINDINGS It was found unexpectedly that exposure to lopinavir is decreased in the first 6 months of life. Recent findings of subtherapeutic efavirenz concentrations in children suggest that pediatric dose recommendations should be re-evaluated. In addition, recommended dosing of lamivudine leads to lower exposure in children younger than 6 years of age. Preliminary results of pediatric fixed-dose combination tablets for HIV-infected children with a higher nevirapine to stavudine and lamivudine ratio than adult fixed-dose combinations suggest adequate drug exposure. As an alternative to plasma sampling, concentrations of nevirapine can be determined in saliva. SUMMARY There is a shortage of pharmacokinetic data in the highly variable population of HIV-infected children. Selected pharmacology studies should be undertaken to improve pediatric dose guidance of existing antiretroviral drugs. Therapeutic drug monitoring is a useful tool to optimize treatment in HIV-infected children. More data are needed, however, to establish child-specific reference values.
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11.0 References. HIV Med 2012. [DOI: 10.1111/j.1468-1293.2012.1030_12.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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8.0 Neonatal management. HIV Med 2012. [DOI: 10.1111/j.1468-1293.2012.1030_9.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Taylor GP, Clayden P, Dhar J, Gandhi K, Gilleece Y, Harding K, Hay P, Kennedy J, Low-Beer N, Lyall H, Palfreeman A, Tookey P, Welch S, Wilkins E, de Ruiter A. British HIV Association guidelines for the management of HIV infection in pregnant women 2012. HIV Med 2012. [DOI: 10.1111/j.1468-1293.2012.01030.x] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- GP Taylor
- Communicable Diseases; Section of Infectious Diseases; Imperial College London; UK
| | - P Clayden
- UK Community Advisory Board representative/HIV treatment advocates network; London; UK
| | - J Dhar
- Genitourinary Medicine; University Hospitals of Leicester NHS Trust; Leicester; UK
| | - K Gandhi
- Heart of England NHS Foundation Trust; Birmingham; UK
| | | | - K Harding
- Guy's and St Thomas′ Hospital NHS Foundation Trust; London; UK
| | - P Hay
- St George's Healthcare NHS Trust; London; UK
| | - J Kennedy
- Homerton University Hospital NHS Foundation Trust; London; UK
| | - N Low-Beer
- Chelsea and Westminster Hospital NHS Foundation Trust; London; UK
| | - H Lyall
- Imperial College Healthcare NHS Trust; London; UK
| | - A Palfreeman
- Genitourinary Medicine; University Hospitals of Leicester NHS Trust; Leicester; UK
| | - P Tookey
- UCL Institute of Child Health; London; UK
| | - S Welch
- Paediatric Infectious Diseases; Heart of England NHS Foundation Trust; Birmingham; UK
| | - E Wilkins
- Infectious Diseases and Director of the HIV Research Unit; North Manchester General Hospital; Manchester; UK
| | - A de Ruiter
- Genitourinary Medicine; Guy's and St Thomas' NHS Foundation Trust; London; UK
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Zhang C, Denti P, Decloedt E, Maartens G, Karlsson MO, Simonsson USH, McIlleron H. Model-based approach to dose optimization of lopinavir/ritonavir when co-administered with rifampicin. Br J Clin Pharmacol 2012; 73:758-67. [PMID: 22126409 PMCID: PMC3403203 DOI: 10.1111/j.1365-2125.2011.04154.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
AIMS Rifampicin, a key component of antitubercular treatment, profoundly reduces lopinavir concentrations. The aim of this study was to develop an integrated population pharmacokinetic model accounting for the drug-drug interactions between lopinavir, ritonavir and rifampicin, and to evaluate optimal doses of lopinavir/ritonavir when co-administered with rifampicin. METHODS Steady-state pharmacokinetics of lopinavir and ritonavir were sequentially evaluated after the introduction of rifampicin and gradually escalating the dose in a cohort of 21 HIV-infected adults. Intensive pharmacokinetic sampling was performed after each dose adjustment following a morning dose administered after fasting overnight. A population pharmacokinetic analysis was conducted using NONMEM 7. RESULTS A simultaneous integrated model was built. Rifampicin reduced the oral bioavailability of lopinavir and ritonavir by 20% and 45% respectively, and it increased their clearance by 71% and 36% respectively. With increasing concentrations of ritonavir, clearance of lopinavir decreased in an E(max) relationship. Bioavailability was 42% and 45% higher for evening doses compared with morning doses for lopinavir and ritonavir, respectively, while oral clearance of both drugs was 33% lower overnight. Simulations predicted that 99.5% of our patients receiving doubled doses of lopinavir/ritonavir achieve morning trough concentrations of lopinavir > 1 mg l(-1) during rifampicin co-administration, and 95% of those weighing less than 50 kg achieve this target already with 600/150 mg doses of lopinavir/ritonavir. CONCLUSIONS The model describes the drug-drug interactions between lopinavir, ritonavir and rifampicin in adults. The higher trough concentrations observed in the morning were explained by both higher bioavailability with the evening meal and lower clearance overnight.
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Affiliation(s)
- Chao Zhang
- Division of Clinical Pharmacology, Department of Medicine, University of Cape TownCape Town, South Africa
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape TownCape Town, South Africa
| | - Eric Decloedt
- Division of Clinical Pharmacology, Department of Medicine, University of Cape TownCape Town, South Africa
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape TownCape Town, South Africa
| | - Mats O Karlsson
- Department of Pharmaceutical Biosciences, Uppsala UniversityUppsala, Sweden
| | | | - Helen McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape TownCape Town, South Africa
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Tseng A, Foisy M, Hughes CA, Kelly D, Chan S, Dayneka N, Giguère P, Higgins N, Hills-Nieminen C, Kapler J, la Porte CJL, Nickel P, Park-Wyllie L, Quaia C, Robinson L, Sheehan N, Stone S, Sulz L, Yoong D. Role of the Pharmacist in Caring for Patients with HIV/AIDS: Clinical Practice Guidelines. Can J Hosp Pharm 2012; 65:125-45. [PMID: 22529405 PMCID: PMC3329905 DOI: 10.4212/cjhp.v65i2.1120] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Alice Tseng
- , BScPhm, PharmD, FSCHP, AAHIVP, is with the Immunodeficiency Clinic of the Toronto General Hospital, Toronto, Ontario
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Assessment of lopinavir pharmacokinetics with respect to developmental changes in infants and the impact on weight band-based dosing. Clin Pharmacol Ther 2011; 91:243-9. [PMID: 22190064 DOI: 10.1038/clpt.2011.218] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Improved antiretroviral therapies are needed for the treatment of HIV-infected infants, given the rapid progression of the disease and drug resistance resulting from perinatal exposure to antiretrovirals. We examined longitudinal pharmacokinetics (PK) data from a clinical trial of lopinavir/ritonavir (LPV/r) in HIV-infected infants in whom therapy was initiated at less than 6 months of age. A population PK analysis was performed using NONMEM to characterize changes in lopinavir (LPV) PK relating to maturational changes in infants, and to assess dosing requirements in this population. We also investigated the relationship between LPV PK and viral dynamic response. Age and ritonavir concentrations were the only covariates found to be significant. Population PK of LPV was characterized by high apparent clearance (CL/F) in young infants, which decreased with increasing age. Although younger infants had lower LPV concentrations, the viral dynamics did not correlate with initial LPV exposure. Monte Carlo simulations demonstrated that WHO weight band-based dosing recommendations predicted therapeutic LPV concentrations and provided drug exposure levels comparable to those resulting from US Food and Drug Administration (FDA)-suggested dosing regimens.
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Urien S, Firtion G, Anderson ST, Hirt D, Solas C, Peytavin G, Faye A, Thuret I, Leprevost M, Giraud C, Lyall H, Khoo S, Blanche S, Tréluyer JM. Lopinavir/ritonavir population pharmacokinetics in neonates and infants. Br J Clin Pharmacol 2011; 71:956-60. [PMID: 21564164 DOI: 10.1111/j.1365-2125.2011.03926.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT • Lopinavir/ritonavir pharmacokinetics have been fully investigated in adults and children. WHAT THIS STUDY ADDS • Lopinavir/ritonavir population pharmacokinetics in 96 neonates and infants from birth to less than 2 years (1.16 to 10.4 kg) showed that CL/F and V/F were dependent on body weight on an allometric basis and post-menstrual age. AIMS Because of immature hepatic metabolism, lopinavir could present specific pharmacokinetics in the first weeks of life. We aimed at determining the optimal dosing regimen in neonates and infants weighing 1 to 10.5 kg. METHODS Lopinavir/ritonavir (LPV/r) pharmacokinetics were studied in 96 infants using a population approach. RESULTS A one-compartment model described LPV/r pharmacokinetics. Normalized to a 70 kg adult using allometry, clearance (CL/F) and distribution volume (V/F) estimates were 5.87|h(-1) 70 kg(-1) and 91.7|70 kg(-1). The relative bioavailabilty, F, increased with post-menstrual age (PMA) and reached 50% of the adult value at 39.7 weeks. CONCLUSIONS Size and PMA explained some CL/F and V/F variability in neonates/infants. Based upon trough concentration limitations, suggested LPV/r dosing regimens were 40 mg 12 h(-1), 80 mg 12 h(-1) and 120 mg 12 h(-1) in the 1-2 kg, 2-6 kg and 6-10 kg group, respectively.
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Affiliation(s)
- Saik Urien
- EA 3620, Université Paris Descartes, Paris, France.
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Pharmacokinetics and virological efficacy after switch to once-daily lopinavir-ritonavir in treatment-experienced HIV-1-infected children. Antimicrob Agents Chemother 2011; 55:4320-5. [PMID: 21746952 DOI: 10.1128/aac.00166-11] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Lopinavir-ritonavir (LPV/r) is a protease inhibitor that is used twice daily (BID) in the treatment of HIV infection in children. In the context of a single-center observational study, a switch to a once-a-day (QD) LPV/r regimen was proposed for considerations of convenience and to support adherence. The aims of this study were to compare the pharmacokinetics, viral loads, percentages of CD4(+) T cells, and lipid profiles after switching from a twice-daily to a once-daily regimen of LPV/r in experienced children. For this purpose, LPV concentrations, viral loads, CD4(+) T cells, and biochemistry data were measured in routine therapeutic drug monitoring procedures in 45 children and adolescents. Thirty-six children were switched to the QD regimen. Nine children on the BID or QD regimen were added for pharmacokinetic-study purposes only. The QD trough concentrations (C(trough)) of lopinavir in plasma were significantly lower than those observed with the BID regimen (P < 0.0001), but the 24-h exposure levels were not significantly lower with the QD than with the BID regimen (P = 0.09). Among 34 evaluable patients who switched from the BID to the QD regimen, the virological efficacy of LPV/r appeared to differ (P < 0.001), with 74% and 57% of viral loads, respectively, being <50 copies/ml (mean follow-up times, 33 and 20 months). Among 22 patients with stable virological control before the switch, 12 experienced either failure or blip (one observation of detectable viral load between two observations of undetectable viral load) after the switch. The change from the BID to the QD regimen did not result in significant differences in CD4(+) T cell percentages or total cholesterol, high-density lipoprotein (HDL) cholesterol, or triglyceride levels. The switch from the BID to the QD LPV/r regimen led to equivalent exposure and lower C(trough) values and resulted in lower levels of virological control in these antiretroviral-experienced children.
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Neely MN, Rakhmanina NY. Pharmacokinetic Optimization of Antiretroviral Therapy in Children and Adolescents. Clin Pharmacokinet 2011; 50:143-89. [DOI: 10.2165/11539260-000000000-00000] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Elsherbiny D, Ren Y, McIlleron H, Maartens G, Simonsson USH. Population pharmacokinetics of lopinavir in combination with rifampicin-based antitubercular treatment in HIV-infected South African children. Eur J Clin Pharmacol 2010; 66:1017-23. [PMID: 20552180 DOI: 10.1007/s00228-010-0847-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2009] [Accepted: 05/19/2010] [Indexed: 11/28/2022]
Abstract
PURPOSE The population pharmacokinetics (PK) of lopinavir in tuberculosis (TB)/human immunodeficiency virus (HIV) co-infected South African children taking super-boosted lopinavir (lopinavir/ritonavir ratio 1:1) as part of antiretroviral treatment in the presence of rifampicin were compared with the population PK of lopinavir in HIV-infected South African children taking standard doses of lopinavir/ritonavir (ratio 4:1). METHODS Lopinavir concentrations were measured in 15 TB/HIV-co-infected paediatric patients who were sampled during and after rifampicin-based TB treatment and in 15 HIV-infected children without TB. During TB therapy, the dose of ritonavir was increased to lopinavir/ritonavir 1:1 in order to compensate for the induction of rifampicin. The children received median (interquartile range=IQR) doses of lopinavir 292 mg/m(2) (274, 309) and ritonavir 301 mg/m(2) (286, 309) twice daily. After TB treatment completion the children received standard doses of lopinavir/ritonavir 4:1 (median [IQR] lopinavir dose 289 mg/m(2) [286, 303] twice daily) as did those without TB (median [IQR] lopinavir dose 265 mg/m(2) [249, 289] twice daily). RESULTS Lopinavir oral clearance (CL/F) was about 30% lower in children without TB than in co-infected children treated with super-boosted lopinavir. However, the predicted lopinavir C(min) was above the recommended minimum therapeutic concentration during TB/HIV co-treatment in the 15 children. Lopinavir CL/F increased linearly during the dosing interval. CONCLUSIONS Increasing the ritonavir dose to achieve a lopinavir/ritonavir ratio of 1:1 when given in combination with rifampicin-based TB treatment did not completely compensate for the enhancement of lopinavir CL/F caused by rifampicin. The time-dependent lopinavir CL/F might be due to a time-dependent recovery from ritonavir inhibition of lopinavir metabolism during the dosing interval.
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Affiliation(s)
- Doaa Elsherbiny
- Department of Pharmaceutical Biosciences, Uppsala University, Box 591, BMC, 751 24 Uppsala, Sweden
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ADME pharmacogenetics: investigation of the pharmacokinetics of the antiretroviral agent lopinavir coformulated with ritonavir. Pharmacogenet Genomics 2010; 20:217-30. [DOI: 10.1097/fpc.0b013e328336eee4] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Abstract
PURPOSE OF REVIEW This review briefly outlines the influences of gender and pregnancy on drug disposition, and describes the available antiretroviral pharmacokinetic data and dosing recommendations in these groups. RECENT FINDINGS Recent studies in pregnant women continue to document altered exposure of different classes of drugs during pregnancy. While new information shows that tenofovir exposure is significantly decreased during pregnancy, the magnitude of the decrease will not likely necessitate dose changes, similar to other nucleoside reverse transcriptase inhibitors. In contrast, standard doses of lopinavir/ritonavir in the third trimester showed markedly decreased exposure, and higher doses of this co-formulated agent should be given to women during the third trimester. Likewise, nelfinavir exposure using the new 625-mg tablets is also decreased during pregnancy, and higher doses should be considered in the third trimester. SUMMARY The majority of antiretrovirals studied have altered pharmacokinetics during pregnancy. Understanding the extent of these changes is necessary to recommend dose changes during pregnancy when appropriate. The correct dose is critical to maintain efficacy and safety of these agents for both the mother and the fetus. Innovative study designs are needed to facilitate the study of antiretrovirals during pregnancy.
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Anderson GD, Lynn AM. Optimizing pediatric dosing: a developmental pharmacologic approach. Pharmacotherapy 2009; 29:680-90. [PMID: 19476420 DOI: 10.1592/phco.29.6.680] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Many physiologic differences between children and adults can result in age-related differences in pharmacokinetics. Understanding the effects of age on bioavailability, volume of distribution, protein binding, hepatic metabolic isoenzymes, and renal elimination can provide insight into optimizing doses for pediatric patients. We performed a search of English-language literature using the MEDLINE database regarding age and pharmacokinetics (1979-July 2008). We then evaluated the literature with an emphasis on drugs with one primary elimination pathway, such as renal clearance or a pathway involving a single metabolic isoenzyme. Our mechanistic-based analysis revealed that children need weight-corrected doses that are substantially higher than adult doses for drugs that are metabolically eliminated solely by the specific cytochrome P450 (CYP) isoenzymes CYP1A2, CYP2C9, and CYP3A4. In contrast, weight-corrected doses for drugs eliminated by renal excretion or metabolism involving CYP2C19, CYP2D6, N-acetyltransferase 2, or uridine diphosphate glucuronosyltransferases are similar in children and adults. In children, bioavailability of drugs with high first-pass metabolism is decreased for drugs metabolized by CYP1A2, CYP2C9, and CYP3A4. Limited data suggest that by age 5 years, bioavailability of drugs affected by efflux transporters should be equivalent to that of adults. Using a pharmacokinetics-based approach, rational predictions can be made for the effects of age on drugs that undergo similar pathways of elimination, even when specific pharmacokinetic data are limited or unavailable.
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Affiliation(s)
- Gail D Anderson
- Department of Pharmacy, University of Washington, Seattle, Washington 98195, USA.
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Abstract
PURPOSE OF REVIEW This article reviews recent studies in the field of clinical pharmacology of antiretroviral drugs and highlights the relevance of the findings to clinical practice in developing countries. RECENT FINDINGS Differences in antiretroviral pharmacokinetics are associated with polymorphisms of genes encoding drug metabolizing enzymes. Inadequate concentrations of antiretrovirals in children are common. A study in African children found subtherapeutic concentrations in 40% of patients receiving efavirenz at recommended doses. SUMMARY Recent findings on the pharmacokinetics of antiretroviral agents relevant to clinical practice in developing countries are reviewed. Widespread poverty impacts negatively on HIV/AIDS treatment and prevention efforts. Improved access to treatment, social and economic support and pharmacology research in target populations are needed.
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Population pharmacokinetics of lopinavir predict suboptimal therapeutic concentrations in treatment-experienced human immunodeficiency virus-infected children. Antimicrob Agents Chemother 2009; 53:2532-8. [PMID: 19258274 DOI: 10.1128/aac.01374-08] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
In adult protease inhibitor (PI)-experienced patients, a lopinavir (LPV) phenotypic inhibitory quotient (PIQ) of >15 has been associated with a higher likelihood of viral suppression. The aims of this study were to develop a population pharmacokinetic (PK) model of LPV in children and to estimate the probability of achieving a PIQ of >15. HIV-infected, PI-experienced children receiving LPV were intensively sampled for 12 h to measure plasma LPV. The data were fitted to candidate PK models (using MM-USCPACK software), and the final model was used to simulate 1,000 children to determine the probability of achieving an LPV PIQ of >15. In 50 patients (4 to 18 years old), the median LPV plasma 12-hour-postdose concentration was 5.9 mg/liter (range, 0.03 to 16.2 mg/liter) lower than that reported in adults. After a delay, LPV was absorbed linearly into a central compartment whose size was dependent on the weight and age of the patient. Elimination was dependent on weight. The regression line of observed versus predicted LPV had an R(2) of 0.99 and a slope of 1.0. Visual predictive checks against all available measured concentrations showed good predictive ability of the model. The probability of achieving an LPV PIQ of >15 was >90% for wild-type virus but <10% for even moderately resistant virus. The currently recommended dose of LPV/ritonavir appears to be adequate for children infected with wild-type virus but is unlikely to provide adequate inhibitory concentrations for even moderately resistant human immunodeficiency virus (HIV). PI-experienced HIV-infected children will likely benefit from longitudinal, repeated LPV measurement in plasma to ensure that drug exposure is most often near the maximal end of the observed safe range.
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Pharmacokinetics of high-dose lopinavir-ritonavir with and without saquinavir or nonnucleoside reverse transcriptase inhibitors in human immunodeficiency virus-infected pediatric and adolescent patients previously treated with protease inhibitors. Antimicrob Agents Chemother 2008; 52:3276-83. [PMID: 18625762 DOI: 10.1128/aac.00224-08] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Human immunodeficiency virus (HIV)-infected children and adolescents who are failing antiretrovirals may have a better virologic response when drug exposures are increased, using higher protease inhibitor doses or ritonavir boosting. We studied the pharmacokinetics and safety of high-dose lopinavir-ritonavir (LPV/r) in treatment-experienced patients, using an LPV/r dose of 400/100 mg/m(2) orally every 12 h (p.o. q12h) (without nonnucleoside reverse transcriptase inhibitor [NNRTI]), or 480/120 mg/m(2) p.o. q12h (with NNRTI). We calculated the LPV inhibitory quotient (IQ), and when the IQ was <15, saquinavir (SQV) 750 mg/m(2) p.o. q12h was added to the regimen. We studied 26 HIV-infected patients. The median age was 15 years (range, 7 to 17), with 11.5 prior antiretroviral medications, 197 CD4 cells/ml, viral load of 75,577 copies/ml, and a 133-fold change in LPV resistance. By treatment week 2, 14 patients had a viral-load decrease of >0.75 log(10), with a median maximal decrease in viral load of -1.57 log(10) copies/ml at week 8. At week 2, 19 subjects showed a median LPV area under the concentration-time curve (AUC) of 157.2 (range, 62.8 to 305.5) microg x h/ml and median LPV trough concentration (C(trough)) of 10.8 (range, 4.1 to 25.3) microg/ml. In 16 subjects with SQV added, the SQV median AUC was 33.7 (range, 4.4 to 76.5) microg x h/ml and the median SQV C(trough) was 2.1 (range, 0.2 to 4.1) microg/ml. At week 24, 18 of 26 (69%) subjects remained in the study. Between weeks 24 and 48, one subject withdrew for nonadherence and nine withdrew for persistently high virus load. In antiretroviral-experienced children and adolescents with HIV, high doses of LPV/r with or without SQV offer safe options for salvage therapy, but the modest virologic response and the challenge of adherence to a regimen with a high pill burden may limit the usefulness of this approach.
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Delaugerre C, Warszawski J, Chaix ML, Veber F, Macassa E, Buseyne F, Rouzioux C, Blanche S. Prevalence and risk factors associated with antiretroviral resistance in HIV-1-infected children. J Med Virol 2007; 79:1261-9. [PMID: 17607781 DOI: 10.1002/jmv.20940] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
In the USA and West Europe, nearly 80% of HIV-1-infected adults, experiencing virologic failure, harbored virus strain resistant to at least one antiretroviral drug. Limited data are available on antiretroviral drug resistance in pediatric HIV infection. The aims of this study were to analyze prevalence of HIV-1 drug resistance and to identify risk factors associated with resistance in this population. Prevalence of genotypic resistance was estimated retrospectively in treated children who experienced virologic failure (with HIV-1-RNA > 500 copies/ml) followed in Necker hospital between 2001 and 2003. Among 119 children with resistance testing, prevalence of resistance to any drug was 82.4%. Resistance ranged from 76.5% to nucleoside reverse transcriptase inhibitor (NRTI), to 48.7% to non-nucleoside reverse transcriptase inhibitor (NNRTI) and 42.9% to protease inhibitor (PI). Resistance to at least one drug of two classes and three classes (triple resistance) was 31.9 and 26.9%, respectively. Resistance was not associated with geographic origin, HIV-1 subtype, and CDC status. In multivariate analysis, resistance to any drug remained associated independently with current low viral load and high lifetime number of past PI. Triple resistance was independently associated with the high lifetime number of past PI and with gender, particularly among children aged 11 years old or more with a prevalence seven times higher in boys than in girls. In conclusion, antiretroviral resistance is common among treated HIV-1-infected children and prevalence was similar with those observed in adult population in the same year period. However, adolescent boys seem to be at greater risk.
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